Referrals and treatment
19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
20. GMC guidance, ‘Good medical practice’ section 15 says a doctor, ‘must provide a good standard of practice and care. If you [a doctor] assess,diagnose or treat patients, you must:
a. adequately assess the patient’s conditions, taking account of theirhistory (including the symptoms and psychological, spiritual, socialand cultural factors), their views and values; where necessary,examine the patientb. promptly provide or arrange suitable advice, investigations ortreatment where necessaryc. refer a patient to another practitioner when this serves the patient’s needs.’
21. Mr O says doctors at the Practice did not make the correct referrals or treat him for the symptoms he experienced in his spine since 2019. He says his physical health has deteriorated gradually since this time resulting in decompression surgery in 2023.
22. The Practice said it took Mr O’s health concerns seriously. It said since 2020 it had referred him to cardiology (heart and blood vessel specialists), ENT (ear, nose, and throat), respiratory (specialists in breathing problems) and gastroenterology (specialists in the digestive system) with thorough investigations undertaken. It also said as soon as Mr O presented with neurological symptoms, the Practice referred him promptly for an MRI scan.
23. The Practice also said doctors needed to focus on the psychological aspects of Mr O’s treatment alongside his physical health concerns.
24. We can see from Mr O’s medical records doctors at the Practice referred him to several specialists between 2019 and 2023. We can see it referred him to respiratory, ENT, cardiology, gastroenterology, and rheumatology (an expert who diagnoses and treats arthritis and other diseases of the joints, muscles, and bones) specialists.
25. We can also see Mr O presented at the Practice with multiple symptoms from 2019 onwards, including back pain.
26. On 13 May 2022, we can see a GP at the Practice examined Mr O and noted ‘some lower back pain’ and the ‘sensation in legs feels worse.’ We can also see from Mr O’s medical records that the doctor reviewed these symptoms and wrote ‘no red flags’ and ‘nothing to suggest acute neurology or radiculopathy [where a nerve root in the spine is pinched or irritated]’.
27. Our adviser said that as the neurological examination was normal up to this time, the Practice did not need to refer Mr O to specialists. They confirmed a GP would not refer a patient to neurology for back pain generally. Our adviser also confirmed that the Practice acted within section 15 of the above GMC guidelines in their assessments and referrals to this date.
28. On 19 May 2023, Mr O attended the Practice and a clinician reviewed his symptoms. They noted ‘lower limb paraesthesia’ (an abnormal sensation of the skin with no obvious physical cause) and suggested a GP review him.
29. We can see on 22 May 2023, a GP from the Practice reviewed Mr O and noted new neurological symptoms. They saw ‘pain in both legs and numbness in his left foot.’ The GP also recorded that Mr O had a few occasions where his left leg had been shaking without an obvious cause. His medical records also say Mr O could not put a lot of pressure on his left leg and he could not walk heel to toe.
30. Following this appointment, we can see the GP referred Mr O to a neurologist and for an MRI scan of his head. The radiologist who completed the scan then recommended a referral for an MRI scan of his spine which the Practice completed. On 26 May 2023, we can see in his records the Practice wrote, ‘spine MRI is being arranged’.
31. From the spinal MRI scan, clinicians diagnosed foraminal stenosis, canal stenosis and cervical spondylosis. The British Association of Spine Surgeons describes the symptoms of spinal stenosis (the general name for different types of stenosis in the spine) as back pain and leg pain. Its website says, ‘Most typically it occurs as you walk a pain and will cause numbness or weakness or feelings of unsteadiness sometimes in both legs sometimes in just one’. It also says a specialist would request an MRI scan which would diagnose this condition.
32. The NHS website says symptoms of cervical spondylosis include neck and shoulder pain or stiffness that come and go.
33. Mr O had decompression surgery on 30 August 2023. Clinicians at the Practice reviewed him on 1 September following his discharge and noted the ‘surgeons happy re: the op [operation], no new neurology and generally feeling great post op, bar the pain in the operative area’.
34. We understand Mr O received several diagnoses following his spinal MRI scan which he believes the Practice failed to recognise earlier. We can see he attended the Practice numerous times between 2019 and May 2023 and discussed spinal symptoms. We know this was a worrying time for him.
35. Despite the outcome (including damage to his spine), we have not found any evidence doctors at the Practice could have known this or should have acted differently with the symptoms Mr O presented with between 2019 and May 2023.
36. Our adviser gave their view the GP would only refer a patient to neurology with new neurological symptoms which does not include back pain generally. After a review of Mr O’s record, our adviser confirmed a referral was not indicated before May 2023. They also said the conditions clinicians diagnosed Mr O with can progress over a number of years and can be difficult to diagnose.
37. Regarding his treatment, our adviser also said the GPs at the Practice took appropriate histories for the symptoms Mr O presented with. They examined him and referred him to multiple specialists during this time. From their review of Mr O’s records, our adviser also said the GPs at the Practice prescribed him with appropriate medication, for example codeine (a medicine used to treat pain), when needed and according to his symptoms.
38. Our adviser confirmed the Practice therefore acted within the above GMC guidelines in their referral to neurology, for MRI scans and in its treatment of Mr O for his spinal symptoms.
39. As we have found no indications the Practice has done anything wrong, we will take no further action on this issue.
40. We acknowledge the difficult time Mr O has had over the past few years and the various symptoms he has experienced. We know while he now faces many challenges in his life, we are pleased to hear the decompression surgery has improved some symptoms. We hope we have provided some reassurance that the GPs at the Practice could not have referred him to specialists earlier than they did.